HomeMy WebLinkAboutPermit Backflow Test 2001-2-7
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225 FIFTH STREET
SPRINGFIELD, OR 97477
(541) 726.3753
FAX (541) 726.3689
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: .:r/7 If:yA~ /2 L
ASSESSORS HAP #: 1,0 S Z ::,'-/ ~
OIINER: . r= ~'^ ,,-,or 6 fI-a,,,,, ~"7"
TAX LOT #: 02:,02..
ADDRESS: -=;:>l') \3,,;>,<"
7'-1 Z S-
PHONE #:
STATE: 0 f2-
7L(t( - z. 660
ZIP: 97l(O/
CITY:
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BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50
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CONTRACTOR: ).JU~/-c"< TA'~4A1h..~, d" L4~/LJsc"</A- .::r::.-<.
ADDRESS: :2 o.;J. :l h _"./ t:4~~A" -<v J. -V PHONE #: 9r. r-o ""j .::U ,j -
CITY: 7/<,,--cT7'9 STATE: &~ ZIP: 9'7Y'Jr7
CONSTRUCTION CONTRACTORS REGISTRATION #: /1 -:<'7 ~
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EXPIRES: Y-3""-U
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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DATE
FOR OFFICE USE
DATE OF APPLICATION: OZ 0 70 I
RECEIPT #: ..../ J Y &, ISSUED BY:
TOTAL AMOUNT COLLECTED: cj; 10, ,~
JOB #: 0 C> -0 I Sf 0 -0 (
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